LADA SURVEY 2015

• Member Number

• Audit Title

• Survey Type

  Select Annual High Loss Underwriting request New Member Administrative Claims request LP Follow-up

  • Annual
  • High Loss
  • Underwriting request
  • New Member
  • Administrative
  • Claims request
  • LP Follow-up

• Conducted on

  Date

• LP Representative

  Brandon Kelley

  Randy Hava
• Location
  Address

Contact Information

• Contact - Safety

• Contact - Accounting

• Contact - General

Contact(s)

• Name/ Title

• E-Mail

Loss Information

• ERS Score

• E-Mod

• Inception Date

• Cumulative Loss Ratio

• Loss Ratio (2011-2013)

• Frequency Ratio (2012-2014)

• 2014 Risk Rating (relative to previous years and Fund Average)

  A

  B

  C

  D

  F

• Significant Comments 2014

• Member is having overexertion, strain / lifting claims (Cause Code #1) at a rate above the Fund average (17% of frequency [2014] and 33% of TI [2013].

  Yes

  No

  N/A

• Member is having slip / fall claims (Cause Code #2) at a rate above the Fund average (30% of frequency [2014] and 36% of TI [2013].

  Yes

  No

  N/A

• Member is having Eye Injuries (Cause Code #7) at a rate above the Fund average (10% of frequency [2014] and 2% of TI [2013].

  Yes

  No

  N/A

• Member is having Motor Vehicle Accidents (Cause Code #10) at a rate above the Fund average (11% of frequency [2014] and 13% of TI [2013].

  Yes

  No

  N/A

• Number of Claims 2015

• Loss Ratio for 2015

• Total Incurred 2015

• Average days to Report in 2015

• LP Comments
Comments

Office Survey

• Total Number of Current Employees

• Recent Changes in Operations/ Management Staff
Change

• Is Member maintaining OSHA 300 logs?

  Yes

  No

  N/A

• Comment

• Is Member SIBKQ Compliant?

  Yes

  No

  N/A

• Select No SIBKQ Not Properly Signed Boxes Not Checked Condition not explained/meds not listed Out of Date

  • No SIBKQ
  • Not Properly Signed
  • Boxes Not Checked
  • Condition not explained/meds not listed
  • Out of Date

• Does Member have adequate Drug and Alcohol Policy?

  Yes

  No

  N/A

• Select No Policy No Pre-Hire No Post Accident No With Cause Other

  • No Policy
  • No Pre-Hire
  • No Post Accident
  • No With Cause
  • Other

• Is Member current with GHS/HazCom Compliance?

  Yes

  No

  N/A

• Select GHS Training Not Completed No Written Policy MSDS not provided/ accessible MSDS out of date/missing Other

  • GHS Training Not Completed
  • No Written Policy
  • MSDS not provided/ accessible
  • MSDS out of date/missing
  • Other

• Comments

• Off-Site Locations
New Location

• Name

• Address

Service Manager/ FOM

• Are Quarterly Safety Meetings Held?

  Yes

  No

  N/A

• Is Safety Training conducted?

  Yes

  No

  N/A

• Name and position of person/ entity that conducts safety training

• Frequency of training

  Select Orientation/ Post-hire Daily Weekly Monthly Quarterly Semi-annual/annual Post accident Other

  • Orientation/ Post-hire
  • Daily
  • Weekly
  • Monthly
  • Quarterly
  • Semi-annual/annual
  • Post accident
  • Other

• Are regular Safety inspections performed?

  Yes

  No

  N/A

• Frequency of Inspections

  Select Daily Weekly Monthly Quarterly Semi-annually Post-accident Other

  • Daily
  • Weekly
  • Monthly
  • Quarterly
  • Semi-annually
  • Post-accident
  • Other

• Comment

• Are the dealership's Automotive lifts inspected by a qualified person at least annually?

  Yes

  No

  N/A

• Does the dealership provide orientation training to new hires on the Automotive Lifts found in-house?

  Yes

  No

  N/A

• Is there a daily/ weekly inspection protocol on the Automotive lifts?

  Yes

  No

  N/A

• Does the dealership maintain documentation of the above?

  Yes

  No

  N/A

• Are supplemental resources available for the determination of lift points on unfamiliar vehicles?

  Yes

  No

  N/A

• Resources

  Select On-site manual Online Other

  • On-site manual
  • Online
  • Other

• Comment

• Are supplemental lift devices utilized in service area?

  Yes

  No

  N/A

• Type of device

  Select Light duty stand Screw type stand Single post stand Foot lever stand Farm/ High lift jacks Barrel/ bottle jacks Scissor Jacks Hydraulic Jack Other

  • Light duty stand
  • Screw type stand
  • Single post stand
  • Foot lever stand
  • Farm/ High lift jacks
  • Barrel/ bottle jacks
  • Scissor Jacks
  • Hydraulic Jack
  • Other

• Comment

• Driving Exposure

• Shuttle Service

• Radius (in miles)

• Comments

• Transfer Drivers

• Comments

• Parts Drivers

• Range (in miles)

• Comments

• Towing Service/Roadside Assistance

• Hours of operation

  24 Hour

  Standard working hours

  Other

• Comments

Underwriting/Claims

• Underwriting
Underwriting Concerns

• Claims
Claims Concerns

• Emergency Exit(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select No Sign Sign not visible/illuminated Exit Obstructed/locked Not enough marked exits Other

  • No Sign
  • Sign not visible/illuminated
  • Exit Obstructed/locked
  • Not enough marked exits
  • Other

• Comments

• Fire Extinguisher(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select Inspection out of date No location sign Under/over charged Not secured No extinguisher Wrong type Access obstructed other

  • Inspection out of date
  • No location sign
  • Under/over charged
  • Not secured
  • No extinguisher
  • Wrong type
  • Access obstructed
  • other

• Comment

• Floors

  Satisfactory

  Unsatisfactory

• Hazard

  Select Excessive clutter/ trip hazard Excessive fluids/oil/water Open pits/holes in floor Cords/hoses left out trip hazard Other

  • Excessive clutter/ trip hazard
  • Excessive fluids/oil/water
  • Open pits/holes in floor
  • Cords/hoses left out trip hazard
  • Other

• Comment

• Compressed gas storage

  Satisfactory

  Unsatisfactory

• Hazard

  Select Improperly secured Improperly stored Not properly separated Missing valve cap Pressure guage missing cover Other

  • Improperly secured
  • Improperly stored
  • Not properly separated
  • Missing valve cap
  • Pressure guage missing cover
  • Other

• Comment

• Other
Other

• Add media

  Media

• Comment

• Shop

• Bench Grinder

  Satisfactory

  Unsatisfactory

• Hazard

  Select Gap from work rest exceeds 1/8" Gap for top tongue guard exceeds1/4" Eye Protection sign not visible Poor Housekeeping Other

  • Gap from work rest exceeds 1/8"
  • Gap for top tongue guard exceeds1/4"
  • Eye Protection sign not visible
  • Poor Housekeeping
  • Other

• Comments

• Breaker Box(es)

  Satisfactory

  Unsatisfactory

• Hazard

  Select Access obstructed Breakers not labeled Open slots Exposed wiring Other

  • Access obstructed
  • Breakers not labeled
  • Open slots
  • Exposed wiring
  • Other

• Comments

• Chemical Labeling/Storage

  Satisfactory

  Unsatisfactory

• Hazard

  Select Primary Container improperly/not labeled Secondary container not labeled Improper container Chemicals stored improperly together No bond wire No ground wire Chemicals stored above eye level Other

  • Primary Container improperly/not labeled
  • Secondary container not labeled
  • Improper container
  • Chemicals stored improperly together
  • No bond wire
  • No ground wire
  • Chemicals stored above eye level
  • Other

• Comments

• Compressed Gas Storage

  Satisfactory

  Unsatisfactory

• Hazard

  Select Improperly secured Improperly stored Not properly separated Missing valve cap Pressure guage missing cover Other

  • Improperly secured
  • Improperly stored
  • Not properly separated
  • Missing valve cap
  • Pressure guage missing cover
  • Other

• Comments

• Electrical/Cords

  Satisfactory

  Unsatisfactory

• Hazard

  Select Exposed Wiring Extension cord used for permanent power Improper splicing Frayed/Kinked cords Other

  • Exposed Wiring
  • Extension cord used for permanent power
  • Improper splicing
  • Frayed/Kinked cords
  • Other

• Observed

• Emergency Exit(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select No Sign Sign not visible/illuminated Exit Obstructed/locked Not enough marked exits Other

  • No Sign
  • Sign not visible/illuminated
  • Exit Obstructed/locked
  • Not enough marked exits
  • Other

• Comments

• Eyewash Station(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select No station No sign Broken/not properly working No drain Other

  • No station
  • No sign
  • Broken/not properly working
  • No drain
  • Other

• Comments

• Fire Extinguisher(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select Inspection out of date No location sign Under/over charged Not secured No extinguisher Wrong type Access obstructed other

  • Inspection out of date
  • No location sign
  • Under/over charged
  • Not secured
  • No extinguisher
  • Wrong type
  • Access obstructed
  • other

• Comments

• Floors

  Satisfactory

  Unsatisfactory

• Hazard

  Select Excessive clutter/ trip hazard Excessive fluids/oil/water Open pits/holes in floor Cords/hoses left out trip hazard Other

  • Excessive clutter/ trip hazard
  • Excessive fluids/oil/water
  • Open pits/holes in floor
  • Cords/hoses left out trip hazard
  • Other

• Comments

• Hazard Sign Missing
Hazard sign

• Type

  Select Eye protection Flammable High Voltage No Smoking Corrosive Hand Protection Caution Warning Danger PPE Required

  • Eye protection
  • Flammable
  • High Voltage
  • No Smoking
  • Corrosive
  • Hand Protection
  • Caution
  • Warning
  • Danger
  • PPE Required

• Location

• Comments

• Add media

  Media

• Hoses

  Satisfactory

  Unsatisfactory

• Hazard

  Select Hose improperly repaired Hose improperly stored Hose left out Trip/Fall Hazard Other

  • Hose improperly repaired
  • Hose improperly stored
  • Hose left out Trip/Fall Hazard
  • Other

• Comments

• Housekeeping

  Satisfactory

  Unsatisfactory

• Hazard

  Select Shop Rags not contained properly Excessive build-up at station Food/drink in work area Excessive clutter Flammable Materials stored near ignition source Cardboard Boxes on floor BG Cans improperly stored Unsecured Ladder used batteries improperly stored Other

  • Shop Rags not contained properly
  • Excessive build-up at station
  • Food/drink in work area
  • Excessive clutter
  • Flammable Materials stored near ignition source
  • Cardboard Boxes on floor
  • BG Cans improperly stored
  • Unsecured Ladder
  • used batteries improperly stored
  • Other

• Comments

• Hydraulic Lifts

  Satisfactory

  Unsatisfactory

• Hazard

  Select no inspection certificate expired certificate parts missing/worn/broken Other

  • no inspection certificate
  • expired certificate
  • parts missing/worn/broken
  • Other

• Comments

• Spring Compressor

  Satisfactory

  Unsatisfactory

• Hazard

  Select No Hazard Sign(s) No PPE/Insufficient PPE Apparent at station Other

  • No Hazard Sign(s)
  • No PPE/Insufficient PPE Apparent at station
  • Other

• Comments

• Tools

  Satisfactory

  Unsatisfactory

• Hazard

  Select Missing Guards Frayed/Kinked cords Exposed Wiring Spliced cord Modified Improper repair Other

  • Missing Guards
  • Frayed/Kinked cords
  • Exposed Wiring
  • Spliced cord
  • Modified
  • Improper repair
  • Other

• Comments

• Used Oil Containment

  Satisfactory

  Unsatisfactory

• Hazard

  Select Improper Container Not Properly labeled Hazardous Location Used oil filters imp. contained Other

  • Improper Container
  • Not Properly labeled
  • Hazardous Location
  • Used oil filters imp. contained
  • Other

• Comments

• Other
Observed

• Hazard

• Location

• Comment

• Add media

  Media

• Parts

• Breaker Boxes

  Satisfactory

  Unsatisfactory

• Hazard

  Select Access obstructed Breakers not labeled Open slots Exposed wiring Other

  • Access obstructed
  • Breakers not labeled
  • Open slots
  • Exposed wiring
  • Other

• Comments

• Chemical Storage/Labeling

  Satisfactory

  Unsatisfactory

• Hazard

  Select Primary Container improperly/not labeled Secondary container not labeled Improper container Chemicals stored improperly together No bond wire No ground wire Chemicals stored above eye level Other

  • Primary Container improperly/not labeled
  • Secondary container not labeled
  • Improper container
  • Chemicals stored improperly together
  • No bond wire
  • No ground wire
  • Chemicals stored above eye level
  • Other

• Comments

• Compressed Gas Cylinders

  Satisfactory

  Unsatisfactory

• Hazard

  Select Improperly secured Improperly stored Not properly separated Missing valve cap Pressure guage missing cover Other

  • Improperly secured
  • Improperly stored
  • Not properly separated
  • Missing valve cap
  • Pressure guage missing cover
  • Other

• Comments

• Emergency Exit(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select No Sign Sign not visible/illuminated Exit Obstructed/locked Not enough marked exits Other

  • No Sign
  • Sign not visible/illuminated
  • Exit Obstructed/locked
  • Not enough marked exits
  • Other

• Comments

• Eyewash Station(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select No station No sign Broken/not properly working No drain Other

  • No station
  • No sign
  • Broken/not properly working
  • No drain
  • Other

• Comments

• Fire Extinguisher(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select Inspection out of date No location sign Under/over charged Not secured No extinguisher Wrong type Access obstructed other

  • Inspection out of date
  • No location sign
  • Under/over charged
  • Not secured
  • No extinguisher
  • Wrong type
  • Access obstructed
  • other

• Comments

• Floors

  Satisfactory

  Unsatisfactory

• Hazard

  Select Excessive clutter/ trip hazard Excessive fluids/oil/water Open pits/holes in floor Cords/hoses left out trip hazard Other

  • Excessive clutter/ trip hazard
  • Excessive fluids/oil/water
  • Open pits/holes in floor
  • Cords/hoses left out trip hazard
  • Other

• Observed

• Housekeeping

  Satisfactory

  Unsatisfactory
Observed

• Hazard

  Select Shop Rags not contained properly Excessive build-up at station Food/drink in work area Excessive clutter Flammable Materials stored near ignition source Cardboard Boxes on floor BG Cans improperly stored Unsecured Ladder used batteries improperly stored Other

  • Shop Rags not contained properly
  • Excessive build-up at station
  • Food/drink in work area
  • Excessive clutter
  • Flammable Materials stored near ignition source
  • Cardboard Boxes on floor
  • BG Cans improperly stored
  • Unsecured Ladder
  • used batteries improperly stored
  • Other

• Comments

• Lighting

  Satisfactory

  Unsatisfactory

• Select Low lighting No light covers Exposed wiring Other

  • Low lighting
  • No light covers
  • Exposed wiring
  • Other

• Comments

• Storage

  Satisfactory

  Unsatisfactory

• Hazard

  Select materials stored too close to ceiling Used batteries improperly stored Obstructing walkway Obstructing exit(s) Other

  • materials stored too close to ceiling
  • Used batteries improperly stored
  • Obstructing walkway
  • Obstructing exit(s)
  • Other

• Hazard

  Select No secondary Containment/Stored on ground No Caution signs No PPE available Improper ventilation Other

  • No secondary Containment/Stored on ground
  • No Caution signs
  • No PPE available
  • Improper ventilation
  • Other

• Comments

• Observed

• Second level Storage

  Satisfactory

  Unsatisfactory

• Hazard

  Select Overhead Hazard Lighting Hazard Receiving Gate not Adequate No Toeboards No Load Rating Obs. Other

  • Overhead Hazard
  • Lighting Hazard
  • Receiving Gate not Adequate
  • No Toeboards
  • No Load Rating Obs.
  • Other

• Comments

• Other
Observed

• Location

• Hazard

• Comment

• Add media

  Media

• Body Shop

• Bench Grinder

  Satisfactory

  Unsatisfactory

• Hazard

  Select Gap from work rest exceeds 1/8" Gap for top tongue guard exceeds1/4" Eye Protection sign not visible Poor Housekeeping Other

  • Gap from work rest exceeds 1/8"
  • Gap for top tongue guard exceeds1/4"
  • Eye Protection sign not visible
  • Poor Housekeeping
  • Other

• Comments

• Breaker Boxes

  Satisfactory

  Unsatisfactory

• Hazard

  Select Access obstructed Breakers not labeled Open slots Exposed wiring Other

  • Access obstructed
  • Breakers not labeled
  • Open slots
  • Exposed wiring
  • Other

• Comments

• Chemical Storage/Labeling

  Satisfactory

  Unsatisfactory

• Are Primary Containers Properly Bonded/Grounded?

  Yes

  No

  N/A

• Are Chemicals stored below eye level?

  Yes

  No

  N/A

• Hazard

  Select Primary Container improperly/not labeled Secondary container not labeled Improper container Chemicals stored improperly together No bond wire No ground wire Chemicals stored above eye level Other

  • Primary Container improperly/not labeled
  • Secondary container not labeled
  • Improper container
  • Chemicals stored improperly together
  • No bond wire
  • No ground wire
  • Chemicals stored above eye level
  • Other

• Comments

• Compressed Gas Storage

  Satisfactory

  Unsatisfactory

• Hazard

  Select Improperly secured Improperly stored Not properly separated Missing valve cap Pressure guage missing cover Other

  • Improperly secured
  • Improperly stored
  • Not properly separated
  • Missing valve cap
  • Pressure guage missing cover
  • Other

• Comments

• Electrical/ Cords

  Satisfactory

  Unsatisfactory

• Hazard

  Select Exposed Wiring Extension cord used for permanent power Improper splicing Frayed/Kinked cords Other

  • Exposed Wiring
  • Extension cord used for permanent power
  • Improper splicing
  • Frayed/Kinked cords
  • Other

• Comments

• Emergency Exit(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select No Sign Sign not visible/illuminated Exit Obstructed/locked Not enough marked exits Other

  • No Sign
  • Sign not visible/illuminated
  • Exit Obstructed/locked
  • Not enough marked exits
  • Other

• Comments

• Eyewash Station(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select No station No sign Broken/not properly working No drain Other

  • No station
  • No sign
  • Broken/not properly working
  • No drain
  • Other

• Fire Extinguisher(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select Inspection out of date No location sign Under/over charged Not secured No extinguisher Wrong type Access obstructed other

  • Inspection out of date
  • No location sign
  • Under/over charged
  • Not secured
  • No extinguisher
  • Wrong type
  • Access obstructed
  • other

• Floors

  Satisfactory

  Unsatisfactory

• Hazard

  Select Excessive clutter/ trip hazard Excessive fluids/oil/water Open pits/holes in floor Cords/hoses left out trip hazard Other

  • Excessive clutter/ trip hazard
  • Excessive fluids/oil/water
  • Open pits/holes in floor
  • Cords/hoses left out trip hazard
  • Other

• Comments

• Hazard Sign Missing
Hazard Sign

• Select Eye protection Flammable High Voltage No Smoking Corrosive Hand Protection Caution Warning Danger PPE Required

  • Eye protection
  • Flammable
  • High Voltage
  • No Smoking
  • Corrosive
  • Hand Protection
  • Caution
  • Warning
  • Danger
  • PPE Required

• Location

• Add media

  Media

• Hoses

  Satisfactory

  Unsatisfactory

• Hazard

  Select Hose improperly repaired Hose improperly stored Hose left out Trip/Fall Hazard Other

  • Hose improperly repaired
  • Hose improperly stored
  • Hose left out Trip/Fall Hazard
  • Other

• Comments

• Housekeeping

  Satisfactory

  Unsatisfactory

• Hazard

  Select Shop Rags not contained properly Excessive build-up at station Food/drink in work area Excessive clutter Flammable Materials stored near ignition source Cardboard Boxes on floor BG Cans improperly stored Unsecured Ladder used batteries improperly stored Other

  • Shop Rags not contained properly
  • Excessive build-up at station
  • Food/drink in work area
  • Excessive clutter
  • Flammable Materials stored near ignition source
  • Cardboard Boxes on floor
  • BG Cans improperly stored
  • Unsecured Ladder
  • used batteries improperly stored
  • Other

• Comments

• Paint booth

  Satisfactory

  Unsatisfactory

• Hazard

  Select Inadequate ventilation Light covers cracked/missing Poor housekeeping Other

  • Inadequate ventilation
  • Light covers cracked/missing
  • Poor housekeeping
  • Other

• Comments

• Mixing Room

  Satisfactory

  Unsatisfactory

• Hazard

  Select Door Left open Inadaquate Ventilation Inadaquate Signage Ignition source Obs. Open Containers Other

  • Door Left open
  • Inadaquate Ventilation
  • Inadaquate Signage
  • Ignition source Obs.
  • Open Containers
  • Other

• Comments

• Respirator(s)

• Type Used

• Fit test

  Yes

  No

  N/A

• Date of Fit test

  Date

• Current Medical Clearance?

  Yes

  No

  N/A

• Tools

  Satisfactory

  Unsatisfactory

• Hazard

  Select Missing Guards Frayed/Kinked cords Exposed Wiring Spliced cord Modified Improper repair Other

  • Missing Guards
  • Frayed/Kinked cords
  • Exposed Wiring
  • Spliced cord
  • Modified
  • Improper repair
  • Other

• Comment

• Other
Observed

• Add media

  Media

• Station

• Breaker Boxes

  Satisfactory

  Unsatisfactory

• Hazard

  Select Access obstructed Breakers not labeled Open slots Exposed wiring Other

  • Access obstructed
  • Breakers not labeled
  • Open slots
  • Exposed wiring
  • Other

• Comments

• Chemical Storage/Labeling

  Satisfactory

  Unsatisfactory

• Hazard

  Select Primary Container improperly/not labeled Secondary container not labeled Improper container Chemicals stored improperly together No bond wire No ground wire Chemicals stored above eye level Other

  • Primary Container improperly/not labeled
  • Secondary container not labeled
  • Improper container
  • Chemicals stored improperly together
  • No bond wire
  • No ground wire
  • Chemicals stored above eye level
  • Other

• Comments

• Compressed Gas Storage

  Satisfactory

  Unsatisfactory

• Hazard

  Select Improperly secured Improperly stored Not properly separated Missing valve cap Pressure guage missing cover Other

  • Improperly secured
  • Improperly stored
  • Not properly separated
  • Missing valve cap
  • Pressure guage missing cover
  • Other

• Comments

• Electrical/ Cords

  Satisfactory

  Unsatisfactory

• Comments

• Emergency Exit(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select No Sign Sign not visible/illuminated Exit Obstructed/locked Not enough marked exits Other

  • No Sign
  • Sign not visible/illuminated
  • Exit Obstructed/locked
  • Not enough marked exits
  • Other

• Comments

• Eyewash Station(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select No station No sign Broken/not properly working No drain Other

  • No station
  • No sign
  • Broken/not properly working
  • No drain
  • Other

• Comments

• Hazards

  Select Exposed Wiring Extension cord used for permanent power Improper splicing Frayed/Kinked cords Other

  • Exposed Wiring
  • Extension cord used for permanent power
  • Improper splicing
  • Frayed/Kinked cords
  • Other

• Fire Extinguisher(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select Inspection out of date No location sign Under/over charged Not secured No extinguisher Wrong type Access obstructed other

  • Inspection out of date
  • No location sign
  • Under/over charged
  • Not secured
  • No extinguisher
  • Wrong type
  • Access obstructed
  • other

• Comments

• Floors

  Satisfactory

  Unsatisfactory

• Hazard

  Select Excessive clutter/ trip hazard Excessive fluids/oil/water Open pits/holes in floor Cords/hoses left out trip hazard Other

  • Excessive clutter/ trip hazard
  • Excessive fluids/oil/water
  • Open pits/holes in floor
  • Cords/hoses left out trip hazard
  • Other

• Comments

• Tools

  Satisfactory

  Unsatisfactory

• Hazard

  Select Missing Guards Frayed/Kinked cords Exposed Wiring Spliced cord Modified Improper repair Other

  • Missing Guards
  • Frayed/Kinked cords
  • Exposed Wiring
  • Spliced cord
  • Modified
  • Improper repair
  • Other

• Comments

• Hazard Sign

• Type

  Select Eye protection Flammable High Voltage No Smoking Corrosive Hand Protection Caution Warning Danger PPE Required

  • Eye protection
  • Flammable
  • High Voltage
  • No Smoking
  • Corrosive
  • Hand Protection
  • Caution
  • Warning
  • Danger
  • PPE Required

• Location

• Housekeeping

  Satisfactory

  Unsatisfactory

• Hazard

  Select Shop Rags not contained properly Excessive build-up at station Food/drink in work area Excessive clutter Flammable Materials stored near ignition source Cardboard Boxes on floor BG Cans improperly stored Unsecured Ladder used batteries improperly stored Other

  • Shop Rags not contained properly
  • Excessive build-up at station
  • Food/drink in work area
  • Excessive clutter
  • Flammable Materials stored near ignition source
  • Cardboard Boxes on floor
  • BG Cans improperly stored
  • Unsecured Ladder
  • used batteries improperly stored
  • Other

• Comments

• Other
Observed

• Hazard

• Comments

• Add media

  Media

• Approximate Percentage Eye Protection Compliance (Observed)

• Automatic Compressor(s)

  Satisfactory

  Unsatisfactory

• Hazard

  Select Automatic start sign not displayed/visible Fan/belt guards not in place Other

  • Automatic start sign not displayed/visible
  • Fan/belt guards not in place
  • Other

• Fuel Tanks

  Satisfactory

  Unsatisfactory

• Hazard

  Select Fuel sign missing Flammable sign missing No smoking sign missing Not properly blocked Other

  • Fuel sign missing
  • Flammable sign missing
  • No smoking sign missing
  • Not properly blocked
  • Other

• Plastic Fuel Cans Observed

• Location

• Add media

  Media

• Proximity Marking required for Change in Elevation

• Location

• Add media

  Media
Other

• Location

• Hazard

• Add media

  Media

• Have handouts been given to member?

  Yes

  No

  N/A

• Handouts

  Select LADA Frequently Cited OSHA Standards IA-1 Form Post hire orientation training safety walk-through checklist Other

  • LADA Frequently Cited OSHA Standards
  • IA-1 Form
  • Post hire orientation training
  • safety walk-through checklist
  • Other
Supplemental Handouts

• Handout

• E-Mail Address to send Handouts

• Date

• Comments

• Risk Rating 2014 =

  A

  B

  C

  D

  F

• Risk Rating 2015 =

  A

  B

  C

  D

  F

• Reason #1

• Reason #2

• Reason #3

• Reason #4